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Wealth Namibia Additional lump sum and regular investment

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Published: 07/2020
WN401/Namibia Additional lump sum and regular investment
Wealth Namibia
Additional lump sum and
regular investment
Important information:
1. This request forms part of your investment agreement with us. Refer to the terms of your investment to make sure you can invest additional
amounts and how it will impact your investment where asset exposure regulations apply, or ask your nancial adviser for more information.
2. According to the Financial Intelligence Act (FIA), 13 of 2012, we must identify you, and verify information if it is new or different to what we have
on our records. Based on the information you provide, we may ask for additional information and documents.
3. We populated certain elds on this form to guide you. You can change these elds according to your requirements.
4. You may not change any other part of this form. When you correct any information you have completed, sign next to it.
5. If we cannot process any part of this request, we will inform you or your nancial adviser.
1: Investor details
We need proof of your identity or registration.
1.1 Personal details
Type of investor Natural person Listed company Unlisted company Trust
Other If Other, give more details
Surname/Name of entity
Trading name, if different to the name
of the entity above
Previous surnames/entity/trading
names
Title
Full name
Identication/Registration number
1.2 Communication details
Cell phone number + 2 6 4 (8) Other + 2 6 4
Email address (primary)
Email address (secondary)
If an email indemnity is signed in the investor declaration, the above email address will apply for the receipt of emailed transactions/instructions.
We will communicate by email. Do you prefer to receive communication by post instead? Yes No
If “yes” and the postal address is different to the physical address above, we need the postal address.
Postal address
City/Town
Postal code Country code N A M (NAM if Namibia)
If the investor is a minor,
name of the contact person
Identication number of the
contact person
1.3 Income tax details
If the investor is an entity, we need the Tax addendum for entities form (WN241). Do not complete section 1.3.
Are you a registered tax payer with the Namibia Revenue Agency (NRA)? Yes No
If “yes”, give your tax reference number
Investment number P P
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WN401/Namibia Additional lump sum and regular investment
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Investment number P P
If you are currently, or have been previously, registered for tax in other countries, complete those details below.
Tax residence (country code) Tax identication number (TIN)
Use the list of country codes for the correct country code.
2: Investment details
The additional investment is for a 2.1 Namibia Direct Investment 2.2 Wealth Namibia investment
Individual/Entity submitting and conrming this instruction Investor Mandated adviser
2.1 Namibia Direct Investment: Additional investment, regular investment and unit transfers
The minimum additional investment and investment component amounts are N$200.
2.1.1 Lump sum investment
Lump sum amount N$ ,
Give your investment component selection in section 2.1.3.
2.1.2 Regular investment
If you are requesting a regular investment amount, this instruction will replace any existing regular investment instruction.
We can only collect the regular investment by debit order. You can only ask for a withdrawal or a refund 30 days after we have collected an amount.
Regular amount N$ ,
every
month
every
quarter
every
half year
every
year
Yearly increase in regular amount 0 0 , 0 0 % Month of increase
Give your investment component selection in section 2.1.3
2.1.3 Investment component selection
Investment components Lump sum amount Regular amount
Momentum Namibia Money Market Fund N$ , N$ ,
Momentum Namibia Diversied Income Fund N$ , N$ ,
Momentum Namibia Defensive Growth Fund N$ , N$ ,
Momentum Namibia Diversied Growth Fund of funds N$ , N$ ,
Momentum Namibia Growth Plus Fund of funds N$ , N$ ,
Momentum Namibia Real Growth Core Equity Fund N$ , N$ ,
2.1.4 Unit transfer
For voluntary unit transfers, we need a “Transfer of unit trusts to Momentum Wealth Namibia” form (WN832) for each transfer from a nancial
services provider.
How many nancial services providers are transferring units to us?
2.2 Wealth Namibia Investment: Additional investment, regular investment and unit transfers
2.2.1 Lump sum investment instruction
The minimum additional lump sum investment amount is N$1 000.
Lump sum amount N$ ,
Type of investment Voluntary investment or transfer (Cash transfer)
Also complete section 3 if you are the investment payer.
Alternatively, we need an Investment payer form (WN201)
Compulsory transfer
Complete the recognition of transfer (ROT) for each transfer
using the registration numbers below.
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WN401/Namibia Additional lump sum and regular investment
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Investment number P P
For compulsory transfers from an approved fund or nancial services provider, we need proof of payment for each transfer before we can nalise your
investment application. The table below has the fund registration details.
Registered fund name Wealth Namibia product
Fund registration no
at Namsa
Ministry of Finance -
Inland Revenue fund
registration number
Metropolitan Life Namibia Retirement Annuity Fund Namibia Retirement Annuity 25/7/7/114 10059102-01-4
Metropolitan Preservation Provident Fund Namibia Preservation Provident 12/1/12/342 10059130-01-4
Momentum Preservation Pension Fund Namibia Preservation Pension 12/1/12/341 10059143-01-4
Fee account
You have to invest a portion of your lump sum investment in a fee account from which we deduct ongoing fees. We will use the default investment
component for this purpose and you may choose the percentage allocated to it. We will top up your fee account as needed.
You do not need a fee account if you only use Namibian dollar-denominated collective investment schemes for this investment.
Investment components Fee class Investment allocation %
Fee account
Momentum Namibia Money Market Fund B 1 2 , 5 0 %
Namibian dollar-denominated components
, %
, %
, %
, %
, %
, %
, %
South African rand-denominated components
, %
, %
, %
, %
, %
, %
1 0 0 , 0 0 %
2.2.2 Regular investment instruction
The minimum monthly regular investment amount is N$1 000.
We can only collect the regular investment by debit order. You can only ask for a withdrawal or a refund 30 days after we have collected an amount.
The instruction below replaces any existing regular investment instruction for this investment.
Regular amount N$ ,
every
month
every
quarter
every
half year
every
year
Yearly increase in regular amount 0 0 , 0 0 % Month of increase
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WN401/Namibia Additional lump sum and regular investment
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Investment number P P
Investment instruction
You can only choose Namibian-dollar denominated investment components for the regular investment.
Fee account
You can choose to invest a portion of your regular investment in a fee account, from where we deduct ongoing fees. We will use the default investment
component for this purpose and you may choose the percentage allocated to it. We will top up your fee account as needed.
Investment components Fee class Investment allocation %
Fee account
Momentum Namibia Money Market Fund B 1 2 , 5 0 %
If you do not want a fee account, change this allocation to 0,00%.
Namibian dollar-denominated components
, %
, %
, %
, %
, %
, %
, %
1 0 0 , 0 0 %
2.2.3 Unit transfer
For voluntary unit transfers, we need a Wealth transfer of unit trusts to Momentum Wealth Namibia: Voluntary products only form (WN832) for each
transfer from the nancial services provider (FSP).
How many nancial services providers are transferring units to us?
For compulsory unit transfers, we need a Wealth transfer of unit trusts to Momentum Wealth Namibia: Compulsory products only form (WN831) for
each transfer from the approved fund.
How many approved funds are transferring units to us?
3: Payment details
Are you paying the investment amount from your bank account for the:
Lump sum amount
Yes No
Regular investment amount
Yes No
If “yes”, complete the rest of section 3.
If “no”, complete the Investment Payer form (WN201), unless it is a transfer from a recognised fund where we need the ROT to be completed.
3.1 Payment of the lump sum amount
What is the source of the lump sum amount?
Business prot Interest and dividends Savings Salary Inheritance Other
Give more details like name and nature of the business, name of the nancial institution and the account reference, name of the employer, the estate
that paid the inheritance, or describe “other”:
Read the information below before you choose a payment option.
Electronic transfer Bank deposit Collect from bank account
Electronic transfer
or
bank deposit
After we have reviewed the investment application, we will conrm the bank account details you must use for the electronic
transfer or the bank deposit.
We need a copy of the electronic transfer conrmation or bank deposit slip before we can nalise your investment
application.
Collect from bank
account
If we collect the investment amount, you can only ask for a withdrawal or refund after 30 days. We will wait 30 days before we
exchange any investment amount to a foreign currency.
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Investment number P P
Collect from bank
account
Legislation limits collections to N$500 000 per contribution and N$1 000 000 per day. If we have to collect the investment
amount over a number of days, we will invest each collection in the investment components you choose. The rst collection
will be the initial investment amount and we will report the subsequent collections as additional investment amounts.
We need ofcial proof of your Namibian bank account for the collection, not older than three months.
Name of bank
Branch name
Account number Branch code
Type of account Current/Cheque Savings Transmission
Collection date D D M M Y Y Y Y
If we cannot collect on the date you chose, we will collect on the next possible date.
3.2 Payment of the regular amount
What is the source of the regular amount?
Business prot Interest and dividends Savings Salary Inheritance Other
Give more details like name and nature of the business, name of the nancial institution and the account reference, name of the employer, the estate
that paid the inheritance, or describe “other”:
If you asked for a collection of the lump sum from your bank account, must we use the same bank account for the
regular amount?
Yes No
If “no”, complete your Namibian bank account details for the regular amount. We need ofcial proof of this bank account, not older than three months.
Name of bank
Branch name
Account number Branch code
Type of account Current/Cheque Savings Transmission
Collection day of the month
D D
First collection date
D D M M Y Y Y Y
If we cannot collect on the date you chose, we will collect on the next possible date.
4: Fees
Investment management company, administration and other
The fee and benet proposal, if you have one, sets out the fees that apply to this investment. You can also refer to the relevant minimum disclosure
document (MDD) or fund fact sheet for the applicable investment management company fees. You can ask your nancial adviser for more details.
Financial adviser
We will add VAT to the following fee percentages if the nancial adviser fee is subject to VAT. If the fee differs from your fee and benet proposal, the
fee on this form will apply.
Initial adviser fee: Lump sum investment Initial adviser fee: Regular investment Ongoing adviser fee
0
,
0 0 % excluding VAT 0
,
0 0 % excluding VAT 0
,
0 0 % excluding VAT
5: Financial adviser details and declaration
The servicing nancial adviser must complete and sign this section.
5.1 Financial adviser details
Name and surname
Financial
adviser code FSP name FSP code Fee reference
Fee
split %
Marketing
adviser code
Servicing nancial adviser (preferred adviser)
%
%
%
100
%
Servicing nancial adviser details
Cell phone number
+ 2 6 4 (8) Other + 2 6 4
Email address
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WN401/Namibia Additional lump sum and regular investment
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Investment number P P
5.2 Servicing nancial adviser declaration
1. I conrm that I have identied the investor, any guardian and the investment payer. I obtained and stored the verication
documents and have veried these details as required by the Financial Intelligence Act (FIA).
Yes No
2. I provided and explained to the investor all documents, fees and charges that apply to this investment before this form was signed.
3. I fully comprehend the “S” referencing system embodied in the Namibia Savings and Investment Association
(NASIA) Code of Conduct and I accept the consequences thereof.
Yes No
4. I discussed the impact and costs of a replacement with the investor, as required by the Namibia Savings and Investment Association (NASIA)
replacement policy advice record process. The investor’s response to the replacement question is that it is:
A replacement Not a replacement
If it is a replacement, have completed and attached the replacement policy advice record form.
5. I acknowledge that the client(s) is/are not a resident, national or citizen of the United States of America and is/are not a US person within the
meaning of the denition of that term contained in Regulation S of the US Securities Act 1933 (as amended).
6. Any request I give you will be within the limits of the mandate I have from the investor.
I have read this application form, the terms, the fee and benet proposal, fee schedule and guides that apply to this investment. The information
on this form is to my knowledge, true and correct. I will not hold you liable for any loss or damage if this application is altered after I sign it.
Signature
Date
D D M M Y Y Y Y
6: Investor declaration
1. My investment amount is not the proceeds of any crime.
2. I acknowledge that investment performance is not guaranteed and, if my investment is exposed to market risk, its value may uctuate.
3. It is my responsibility to get advice before making any investment decisions. I accept the risks related to this investment if I choose not to use the
services of a nancial adviser or do not follow my nancial adviser’s advice.
4. I know that my nancial adviser must be appropriately registered under the Long Term Insurance Act whereas Investment Manager is registered
under Determination 4(1)(f) of the Stock Exchange Control Act.
5. Any future request for this investment:
Must be signed by me or the authorised signatory or
Can be signed by my appointed nancial adviser as per
the mandate for this investment
6. Future request for this investment can be emailed to the appointed nancial adviser or Momentum ofce.
7. I, the undersigned, herewith consent that Momentum Wealth Namibia (Pty) Ltd:
• may communicate with me via email and may send all relevant contracts, statements and other information pertaining to my investment to me
to the email address provided in this application;
• I further conrm that the email address provided herein is complete and correct in all respects and undertake that I will inform Momentum
Wealth Namibia (Pty) Ltd immediately of any changes to the details herein contained and specically of any changes to my email address;
• I acknowledge that I am aware that communications sent by email:
– can easily be tampered with;
– intercepted or fraudulently abused by outsiders; and
• I herewith expressly and fully indemnify Momentum Wealth Namibia (Pty) Ltd, its representatives and employees against and waive any
rights in connection with any demand, claim or action, whether directly or indirectly relating to or in connection with any email communication,
unless the matter is as a result of gross negligence or willful misconduct of Momentum Wealth Namibia (Pty) Ltd or any of its employees, in
which case the matter shall be dealt with on its legal merits.
8. If I am also an investment payer, I agree that for this investment:
• you can check my details with my bank and collect money from my bank account; and
• I can sign for this bank account.
9. I understand and accept:
• your timelines, business practices and administrative processes;
• all fees related to this application and that you will pay it from the investment components when it is due;
• that you can invest an amount when you have collected it or once a deposit reects in your bank account;
• the use of a default investment component for certain transactions and investment events; and
• that you can share my personal information within Momentum Metropolitan Namibia Limited, its subsidiaries and contracted service providers
in order to administer my investment and provide me with nancial wellness information.
10. I am aware that the Financial Intelligence Act (FIA) applies and I will follow its requirements.
11. I am/We are not, nor am I/are we acting on behalf of a person(s) who is/are either a resident, national or citizen of the United States of America or
a US person within the meaning of the denition of that term contained in Regulation S of the US Securities Act 1933 (as amended).
Published: 07/2020
WN401/Namibia Additional lump sum and regular investment
7 / 7
Contact details
Client contact centre
Telephone: (+264) 61 297 3737, Fax: (+264) 61 297 3679, Email: wealthservice@momentum.com.na
Address: Cnr Dr Frans Indongo & Werner List Streets, Postal: PO Box 3785 Windhoek Namibia, Website: momentum.com.na
Momentum Wealth Namibia (Pty) Ltd, an authorised nancial services provider Reg no 2016/0297
Momentum Metropolitan Namibia Limited, an authorised nancial services provider Reg no 89/327
Directors: GD Marais, JA Ipinge, JJ Comalie, LCC Rankin
Investment number P P
12. I undertake to inform you in writing of any changes in my circumstances or details I provided within 30 days of any change.
13. I acknowledge that you may be required to send the information provided to the Namibia Revenue Agency, who may share it with the local tax
authority according to the Organisation for Economic Co-operation and Development’s (OECD’s) Common Reporting Standard (CRS).
I have carefully read, and I understand and accept this application, minimum disclosure documents or fund fact sheets and guides that
apply to this investment. The information I completed on this form is true and correct. I will not hold you liable for any loss or damage if
this application is altered after I sign it.
Name and surname
If not the investor, capacity of signatory
Signed at Date D D M M Y Y Y Y
Authorised signatory
Other signature if required
For ofce use:
EMPLOYEE/FINANCIAL ADVISER WHO CONFIRMED RECEIPT OF ALL ORIGINAL DOCUMENTS
Full name
Surname
Employee number
Signature
Date
D D M M Y Y Y Y
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Completed 7 January 2021

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